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254 Legion Cemetery St• _ .... .'.. K., 'Y "i.?, `-' is ... •� Permittee s- i . \DAYIE COUNTY HEALTH DEPARTMENT Name: 11`� Y`A K Environmental Health Section PROPERTY INFORMATIONq/ 3'U1 / ? P.O. Box 848 I D' ctions to property: {„�G' Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 � G �� ` � c rn Section: Lot: ( AUTHORIZATION FOR .- (` t I c �' U I() t, icy WASTEWATER Tax Office PIN:#� LiLI'� SYSTEM CONSTRUCTI N - AUTHORIZATION NO: 0 0 2 3 2 Ac -,t It” o ;t- Road N m �1 tG H L��u. l �i r ip: a 7& t y **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 o G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION 4T, MO/ IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED w M4 RESIDENTIAL SPECIFICATION: BUILDING TYPE 5'r #EDROOMS --3—# BATHS .1. # OCCUPANTS (— GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No (a LOT SIZE �� TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) �`� NEW SITE REPAIR SITE - }� SYSTEM SPECIFICATIONS: TANK SIZE or L.` MP TANK A/ 6AL. TRENCH WIDTH 3 ROCK DEPTH / LINEAR FT OTHER O`I ( � l F_'� P Ol (.t_ et () K REQUIRED SITE MODIFICATIONS/CONDITIONS`: FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERAT ON,�ERMIT e y� SYSTEM INSTALLED BY: N Jo AUTHORIZATION NO. ORATION PERMIT BY: '/ DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 02102 (Revised) `- Permit AVIE COUNTY HEALTH DEPARTMENT t�'� ; �� �/� Name: i Lf 1 ✓Environmental Health Section PROPERTY INFORMATION _ P.O. Box 848 1 Directions to propery:S 1..�' Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 Section: Lot: AUTHORIZATION FOR ' r r G�!{;.i�C.� WASTEWATER Tax Office PIN:#� '`741-')_ Li �1 4G � SYSTEM CONSTRUCTION 002 2 A f+ AUTHORIZATION NO: , Road ame: ;Zip: C *1NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 oSG.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) AL >t_. RESIDENTIAL SPECIFICATION: BUILDING TYPE r #BEDROOMS --3 # BATHS # OCCUPANTS (n GARBAGE DISPOSAL: Yes or No TH SPECIALIST DATE ISSUED ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS., COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE �' T TYPE WATER SUPPLY `" DESIGN WASTEWATER FLOW (GPD)NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE," Y , `GAL.*�PUMP TANK /" /1GAL. TRENCH WIDTH lr ~'ROCK DEPTH =tip LINEAR FT.%3;� ' OTHER lJ` ( tr.! C �� (i c� �• (JLA REQUIRED SITE MODIFICATIONS/CONDITIONS`. 11 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1 i OPERATIONERM Oi^ C f rvFrf r'/ �,�,i,,\ SYSTEM INSTALLED BY: Vt k t�+ AUTHORIZATION NO. OPERATION PERMIT BY:`�i��/ . DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I1 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT;AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME y DCHD 07102 (Revised) NAM ADD aX 4aivieo��t G DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) ONE NUMBE BDIVISION NAME (-C)C- -e VIA -2 e LOT # (Y V " A40" DIRECTIONS TO S 0 DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY --j ► NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER up CD SPECIFY PROBLEM OCCURRING S -e LO a —e Sr aci ct,CA 5 DATE REQUESTED ��-De1 INFORMATION TAKEN BY, This is to certify that the Information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1 f93 Map Frame Davie County, NC - GIS/Mapping System Q i9d F i _ didr llQz 70 slat Oren . � 'C � � '.� �A[�ee laxer ❑ ire �� i-�s �u 0 © PARCELS (Map Tips Available) QWKK Scaffrilk(Caumly ID or Owww 0 Addrt http://maps.co. davie.nc.us/GoMaps/map/mapframe. cfm?CFID=47453&CFTOKEN=69718... 3/25/2009